International Journal of Osteopathic Medicine 51 (2024) 100709

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International Journal of Osteopathic Medicine

journal homepage: www.elsevier.com/locate/ijosm

The inter- and intra-rater reliability of the manual diaphragm assessment

scale in healthy participants
Inês Viegas a, Catarina Francisco a, Edgar Farinha a, Alexandre Nunes a, b, c, *
a
Escola Superior de Saúde Jean Piaget do Algarve, Portugal
b
KinesioLab – Research Unit in Human Movement, Portugal
c
Portugal National Centre, Foundation COME Collaboration, Portugal

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: The main aim of this study was to test the inter and intra-rater reliability of the Manual Diaphragm
Diaphragm Assessment (MED) scale and compared with chest expansion (CE) in healthy participants.
Reliability Methods: A reliability study, with a sample of 45 healthy participants, composed of 30 women and 15 men.
Chest expansion
Participants were evaluated by two raters. The MED assesses seven different points on the diaphragm and rates
Manual diaphragm assessment
its degree of restriction on a scale of 1–5. Upper and lower CE were measured in centimeters with a measuring
tape, which is a valid and reliable method. The intraclass coefficients (ICC) for inter and intra-rater reliability for
CE and MED were calculated for mean measurement consistency using a two-way random effects model.
Results: The intra- and inter-rater reliability of MEDs ranged from low to moderate. The majority of the ICC
values in intra-rater reliability were greater than in inter-rater reliability, and the majority of the ICC values in
both were higher at the left assessment point. CE inter- and intra-reliability ICC varied from moderate to good.
For the upper and lower CE, the inter-rater reliability ICC values were greater than 0.74, and the intra-rater
reliability was greater than 0.71.
Conclusion: The manual evaluation diaphragm scale had poor to moderate intra and inter-reliability. The chest
expansion’s intra and inter-reliability ranged from moderate to good, which was consistent with previous studies.
Measuring chest expansion with a tape is a reliable method of evaluating the diaphragm in a clinical setting.

Implications for practice
• Using a tape to measure chest expansion is a reliable method of
assessing diaphragmatic movement and restriction.
• The manual evaluation diaphragm scale is not reliable for assessing
diaphragmatic movement and restriction.
• Tape measurements of upper and lower chest expansion should be
included in the Osteopathic teaching curriculum and the manual
evaluation diaphragm scale currently cannot be recommended.
1. Introduction
The diaphragm is the primary respiratory muscle, contracting during
inhalation and relaxing during exhalation [1–3]. Manual diaphragm
techniques have been used to improve functions and symptoms in COPD
[4–7], asthma [8], and as an adjunct to inspiratory training in post
COVID-19 symptoms [9]. Moreover, there is some evidence that
targeting the diaphragm can reduce chronic non-specific low back pain
[10,11], chronic neck pain [12] and shoulder pain [13]. The afore­
mentioned outcomes can be explained by these techniques improvement
in the mobility of the spine, costal and posterior muscle chain [14–16],
increase the maximum expiratory pressure [14,17], enhanced forced
vital capacity [17], posture function [18] and improve trunk stabiliza­
tion [19].
As a result, measuring diaphragm function is vital in clinical practice.
The “gold standard” techniques for measuring and assessing diaphragm
mechanical performance are ultrasound and fluoroscopy [20,21].
However, these techniques are not commonly used in clinical practice
due to their time consuming, lack of availability in all medical facilities,
difficulty in visualizing the left hemidiaphragm in obese patients, need
for specialized training, and the high cost of equipment for standard
clinic practice, which includes osteopathic practice [21]. Instead, oste­
opaths use a manual approach for diaphragm assessment, which, while
common and important in osteopathy, is less reliable than other tested

* Corresponding author. Escola Superior de Saúde Jean Piaget do Algarve, Portugal Enxerim, 8300-025, Silves, Portugal.
E-mail address: alexandre.nunes@ipiaget.pt (A. Nunes).

https://doi.org/10.1016/j.ijosm.2024.100709
Received 26 November 2022; Received in revised form 30 October 2023; Accepted 2 January 2024
Available online 4 January 2024
1746-0689/© 2024 Elsevier Ltd. All rights reserved.
I. Viegas et al. International Journal of Osteopathic Medicine 51 (2024) 100709

techniques [22]. The Bordoni et al. [23] study prompted further

research into manual and non-invasive diaphragm assessment methods,
and the Manual Diaphragm Assessment (MED) scale, which uses the
magnitude of movement restriction as a metric of diaphragm dysfunc­
tion, was published in 2019 [24]. However, this scale has not yet been
compared to other scientifically validated methods, and no studies on its
intra and inter-rater reliability have been conducted. The aim of this
study was to estimate the MED’s inter- and intra-rater reliability.

2. Methods

2.1. Participants

The Quality Appraisal Tool for Studies of Diagnostic Reliability

(QAREL) guidelines were followed in the design of this study [25].
Participants included students, faculty, and staff members from the
Superior Health School Jean Piaget Algarve. The inclusion criteria were
adult participants between the ages of 18 and 60, with a BMI between
17.00 and 30.00 kg/m2, who were healthy at the time of data collection,
could communicate in Portuguese, and could collaborate to understand
the requested manoeuvres (Santos et al., 2015 [26]). Exclusion criteria
included pregnant women, individuals with respiratory pathology or a
history of lung diseases, patients with neuromuscular pathology,
musculoskeletal problems, another alteration that alters the respiratory
mechanism, and those who refused to participate in the study.
This study was conducted in accordance with the Declaration of
Helsinki and was approved by the Ethical Council at Institute Piaget
(CEIP) with the approval number: P11–S20-07/06/2022.

2.2. Design

2.2.1. Procedure
Manuel Evaluation Diaphragm Scale (MED) and chest expansion
Fig. 1. Position 5 - xyphoid-costal area.
(CE) were evaluated by two senior osteopathic students, designated as
raters 1 and 2. The two raters completed 6 h of training in both pro­
the CE was measured in centimeters with a tape measure. The upper
cedures. Each rater was in their own room. Repeat measurements were
chest (UP) was measured at the spinous process of the fifth thoracic
used to assess intra-rater reliability by one rater on two different days
vertebra and the third intercostal space at the midclavicular line. The
(R1D1 vs. R1D2) and inter-rater reliability by two raters on the same day
lower chest (LC) was measured between the tenth thoracic vertebra’s
(R1D1 vs. R2D1).
spinous process and the xiphoid process [27] (Fig. 2). The measurements
Participants in the first session were evaluated twice by two different
were taken at the peak of the participant’s maximal inspiration and
raters. Furthermore, demographic data was gathered from a third
maximum expiration. This process was repeated three times, and the
element. The second session, which took place a week later, followed the
average of the results was used in the study. In healthy individuals, the
same format as the first. The data collection session began with the CE
mean value of CE ranges between 4 and 7 cm [28–30], and a decrease in
method and progressed to the MED method.
CE indicates diaphragmatic dysfunction [4]. This method, also known as
To ensure blinding across raters and from past findings, each rater
cirtometry, has been validated and proven to be reliable [4,26,27]. CE
recorded the measures in an empty sheet on day 1 and day 2. All of the
was used as the reference standard in this study.
information and data was gathered by a third senior osteopathic student.
The data was evaluated by a senior researcher who was not aware of the
2.2.4. Demographic data
rater allocation.
The following variables about the participants were collected:
gender, age, weight, height, BMI, smoking habits, and physical activity.
2.2.2. Manuel Evaluation Diaphragm Scale (MED)
The WHO Guidelines on Physical Activity and Sedentary Behavior [31]
Bordoni and Morabito [24] created this scale, which ranges from 1 to
were used to define physical activity as at least 150 min of
5: 1) No restriction on movement; 2) Slight restriction on movement; 3)
moderate-intensity aerobic physical activity per week or more than 75
Medium restriction on movement; 4) Strong restriction on movement; 5)
min of vigorous-intensity aerobic physical activity per week.
No movement. Seven areas of the diaphragm are evaluated: 1) Costal
movements; 2) Anterior costal margin; 3) Diaphragmatic domes; 4)
2.2.5. Statistical analysis
Posterolateral area; 5) Xyphoid-costal area; 6) Medial pillars; 7) Lateral
The G*Power 3.1.9.2 software for Mac OSX [32] was used to
pillars. Each area was assigned a scale value, with regions 1–4 and 7
calculate the required sample size with a power of 80 %, a two-sided
sorted on the right and left sides, respectively, and regions 5 and 6 sorted
t-test, with α = 0.05 giving 45 participants.
globally. Two sessions of the MED were conducted, each followed the
Values are expressed using the mean and standard deviation. The
same protocol (An example is shown in Fig. 1, and all of the picture
intra and inter-rater reliability of CE and MED were examined using
positions are listed in Appendix 1).
intraclass correlation coefficients (ICC). ICCs were calculated for mean
measurement consistency using a two-way random effects model [33].
2.2.3. Upper and lower chest expansion (CE)
ICC estimates and their 95 % confidence intervals were reported. The
A senior student rater assessed each participant’s upper and lower
ICC was interpreted as follows: less than 0.50 – poor reliability; between
CE. The measurement locations were marked with a blue marker, and

2
I. Viegas et al. International Journal of Osteopathic Medicine 51 (2024) 100709

Fig. 2. A – anterior anatomic localizations; B – posterior anatomic localizations; C – Upper chest measurement; D – Lower chest measurement.

0.50 and 0.75 – moderate reliability; between 0.75 and 0.90 – good
Table 1
reliability, and greater than 0.90 – excellent reliability [33].
Participants characteristics.
The reproducibility of the CE measurements was tested using a
paired t-test. All tests were bilateral, with a statistical significance level Characteristic Mean (SD) N %

set at a P value of 0.05. The collected data was statistically analyzed Age (years) 31.04 (11.81)
using the IBM®SPSS® version 25 software. Gender
Feminine 30 66.7
Masculine 15 33.3
3. Results Weight (kg) 64.91 (11,10)
Height (cm) 167.02 (8.82)
A total of 47 participants were recruited, but two were excluded, one BMI (kg/m2) 23.19 (2,93)
due to having a BMI that was higher than the reference values and the Smoking habits
Yes 5 11.1
other due to having a chronic respiratory pathology. Data from 45
No 40 88.9
participants were analyzed for this study, with the demographic and Physical activity
clinical characteristics of the participants shown in Table 1. The data Yes 21 46.7
was presented as mean and standard deviation. No 24 53.3
The intra- and inter-rater reliability of MEDs is shown in Table 2,
ranging from poor to moderate reliability. The majority of the ICC values
lower CE were greater than 0.74, and the intra-rater reliability was
in intra-rater reliability were higher than in inter-rater reliability, and
greater than 0.71. (Table 4).
the majority of the ICC values were higher at the left assessment point.
Intra-rater reliability was moderate for points 1–4 on the left and 5–7 on
4. Discussion
the right (Table 2). Inter-rater reliability was poor for points 4 (only the
left point) to 7 (Table 2).
The manual evaluation of the diaphragm is a common practice in
The upper CE values were lower than the lower CE values, and rater 2
osteopathic consultations, and the main aim of this study was to esti­
consistently had lower values than rater 1. The CE measurements are
mate the MED’s inter- and intra-rater reliability.
summarized in Table 3. The inter- and intra-reliability ICC ranged from
The results of our study revealed that the MED has poor to moderate
moderate to good. The inter-rater reliability ICC values for the upper and
reliability in inter and intra-rater reliability. Points 1 and 2 (lateral side

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I. Viegas et al. International Journal of Osteopathic Medicine 51 (2024) 100709

Table 2
MED intra and inter-rater reliability.
Anatomical Position MED inter-rater reliability MED intra-rater reliability
Landmark
Day ICC CI Rater ICC CI

Lateral right side of the costal margin Position 1 right 1 0.28 − 0.26, 0.60 1 0.65 0.37, 0.81
2 0.35 − 0.17, 0.64 2 0.34 − 0.18, 0.63
Lateral left side of the costal margin Position 1 left 1 0.61 0.29, 0.78 1 0.61 0.28, 0.79
2 0.57 0.23, 0.77 2 0.71 0.48, 0.84
Right anterior costal margin Position 2 right 1 0.24 − 0.36,0.58 1 0.30 − 0.28, 0.62
2 0.27 − 0.29, 0.60 2 0.10 − 0.65, 0.51
Left anterior costal margin Position 2 left 1 0.52 0.13, 0.73 1 0.61 0.29, 0.78
2 0.42 − 0.6, 0.68 2 0.67 0.40, 0.82
Right diaphragmatic dome Position 3 right 1 0.68 0.40, 0.83 1 0.45 − 0.00, 0.70
2 0.40 − 0.04, 0.66 2 0.48 0.04, 0.71
Left diaphragmatic dome Position 3 left 1 0.53 0.16, 0.74 1 0.59 0.25, 0.78
2 0.45 0.03, 0.70 2 0.61 0.28, 0.78
Right posterolateral area Position 4 right 1 0.59 0.25, 0.77 1 0.62 0.31, 0.79
2 0.21 − 0.44, 0.56 2 0.43 0.02, 0.68
Left posterolateral area Position 4 left 1 0.06 − 0.74, 0.49 1 0.49 0.09, 0.72
2 0.29 − 0.29, 0.61 2 0.50 0.09, 0.73
Xyphoid-costal area Position 5 1 0.23 − 0.41, 058 1 0.55 0.18, 0.75
2 0.32 − 0.25, 0.63 2 0.61 0.28, 0.78
Diaphragm medial pillars Position 6 1 − 0.19 − 1.20, 0.35 1 0.64 0.35, 0.80
2 0.30 − 0.27, 0.62 2 0.61 0.28, 0.78
Right diaphragm lateral pillars Position 7 right 1 0.05 − 0.41, 0.40 1 0.62 0.30, 0.80
2 0,35 − 0.09, 0.63 2 0.68 0.41, 0.82
Left diaphragm lateral pillars Position 7 left 1 0.1 − 0.43, 0.46 1 0.71 0.48, 0.84
2 0.42 − 0.01, 0.68 2 0.54 0.15, 0.75

Table 3
Chest expansion values.
R1T1 R2T1 R1T2 R2T2

Upper CE (cm) Lower CE (cm) Upper CE (cm) Lower CE (cm) Upper CE (cm) Lower CE (cm) Upper CE (cm) Lower CE (cm)

Mean 4.04 6.07 3.46 5.56 4.03 6.12 3.24 5.39

SD 1.13 1.97 1.31 1.71 1.29 1.76 1.54 1.65
SE 0.17 0.29 0.19 0.25 0.19 0.26 0.23 0.24
CI 95 % 1.66, 6.33 − 0,84, 8,66 0.0, 6.47 1.40, 8.67 1.83, 7.83 2.24, 10,00 − 0.33, 7.47 2.00, 8.50

CE, chest expansion; R1, rater 1; R2, rater 2; SD, Standard Deviation; SE, Standard Error, T, day.

health participants [26,28,29] and lower than those of Bockenhauer

Table 4
et al. [27], but this study had a small sample size. Even in symptomatic
Intra and interrater reliability for upper and lower chest expansion.
populations, this method produced comparable ICC values in chronic
Inter-rater reliability Intra-rater reliability obstructive pulmonary disease [29,36] and ankylosing spondylitis [28].
Day ICC 95 % CI Rater ICC 95 % CI Furthermore, there was an increase in CE in healthy participants
Upper CE 1 0.78 0.61, 0.88 1 0.84 0.72, 0.91 [14], sedentary women [15], and asthmatic patients [8] in previous
2 0.86 0.75, 0.92 2 0.81 0.66, 0.90 randomised controlled trials using manual diaphragmatic release tech­
Lower CE 1 0.74 0.52, 0.85 1 0.71 0.46, 0.84 niques with the aim of improving chest mobility. A recent systematic
2 0.87 0.76, 0.93 2 0.86 0.75, 0.92 review confirmed that manual diaphragm techniques improve chest
CE, chest expansion; R1, rater 1; R2, rater 2; SD, Standard Deviation; SE, Stan­ mobility (Férnandez-Lopez et al., 2021).
dard Error, T, day. Moreover, as measured by ultrasonography, osteopathic treatment
improves diaphragmatic motion [22]. Notwithstanding, in this study
of the costal margin and anterior costal margin) were evaluated by there was a good correlation between diaphragmatic mobility assessed
different hands, that is, the participant’s left side was evaluated by the by ultrasonography and MED after osteopathic treatment. The author
rater’s right hand, which is the dominant hand in both cases, and this suggested additional research to confirm the MED reliability, which the
may explain why the left side had a slightly higher ICC value than the current study did not support. It should also be noted that the ultraso­
right side. The remaining points, both left and right, were always eval­ nography method used in this study did not permit the assessment of the
uated by the dominant hand, which does not explain the low ICC value. left hemidiaphragm, which was a study limitation. Despite the fact that
A previous study found a wide range of variability in diaphragm chest expansion could not be quantified, osteopathic manipulative
contractibility measured by ultrasound in 150 healthy subjects while treatment, which included diaphragmatic techniques, reduced pain in
breathing normally [34]. This could explain our current findings. patients with chronic low back pain after 12 weeks when compared to
Furthermore, the reliability of manual palpation tests varies signifi­ sham treatment [10]. Furthermore, osteopathic diaphragmatic stretch­
cantly in patients with low back pain [35]. As a result, a critical and ing techniques improve pulmonary function in both healthy and asth­
careful extrapolation from healthy subjects to subjects with low back matic subjects [8,17].
pain is required for diaphragm assessment. According to Férnandez-Lopez et al. (2021), it is critical to train the
In contrast, the upper CE had moderate intra and inter-reliability and health care professional in the correct evaluation of diaphragm mobility.
the lower CE had moderate to good intra and inter-reliability. This The author suggested that the assessment be performed using ultraso­
study’s ICC results were comparable to those of previous research with nography. Nonetheless, the findings of our study and the literature

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I. Viegas et al.
support the use of a tape measure to determine CE. As a result, in the
absence of ultrasonography, this quantitative method should be used to
assess CE.
Finally, our study’s CE mean values were consistent with other
studies [28,29], primarily for lower CE values where upper CE values
were lower. The study by Ref. [29] compared CE between healthy
nonsmokers, healthy smokers, and chronic obstructive pulmonary dis­
ease and found a statistically significant reduction in CE in the chronic
obstructive pulmonary disease group when compared to the other two
groups. As a result, in order to quantify CE normality, health practi­
tioners must have CE normative values from the population based on
age, gender, and BMI. Our research helps to raise CE values in the
healthy Portuguese population.
5. Limitations and recommendations
This reliable study was conducted by senior students, which may
have an effect on the overall ICC scores. As a result, additional research
with more experienced osteopaths or comparisons of different levels of
experience are needed to assess MED reliability. Nonetheless, the CE
intra and inter-rater ICC in this study were comparable to those found in
previous studies. As previously stated, some osteopathic RCTs used this
quantitative method to validate the effect of osteopathic techniques to
improve the diaphragm function. The MED is a subjective evaluation
method that is dependent on the perspective and experience of each
rater, which can lead to differences in reproducibility. As a result, based
on our findings and the literature, we recommend incorporating upper
and lower CE methods into the Osteopathic teaching curriculum and the
MED currently cannot be recommended.
Appendix 1. Images of the Manuel Evaluation Diaphragm Scale (MED)
Position 1 - Lateral side of the costal margin
5
International Journal of Osteopathic Medicine 51 (2024) 100709
The time spent by each rater measuring upper and lower CE should
be quantified to provide a more precise and reliable recommendation for
clinic practice. Finally, while this study provides information on the
mean values of CE in Portuguese healthy individuals, additional
research with larger and more diverse sample sizes is needed.
6. Conclusion
The manual evaluation diaphragm scale had poor to moderate intra
and inter-reliability. The chest expansion’s intra and inter-reliability
ranged from moderate to good, which was consistent with previous
studies. Measuring chest expansion with a tape is a reliable method of
evaluating the diaphragm in a clinical setting and should be incorpo­
rated in the Osteopathic teaching curriculum. To quantify manual
evaluation diaphragm scale reliability, more research is required.
Funding sources
No funding.
Ethical approval
Approved by the Ethical Council at Institute Piaget (CEIP) with the
approval number: P11–S20-07/06/2022.
Declaration of competing interest
We report no conflict of interest.
Position 2 – Anterior Costal margin
(continued on next page)
I. Viegas et al. International Journal of Osteopathic Medicine 51 (2024) 100709

(continued )

Position 3 - diaphragmatic dome (right) Position 4 - Posterolateral area (left)

Position 6 - Diaphragm medial pillar

Position 5 - Xyphoid-costal area

Position 7 - Diaphragm lateral pillars (left)

Note – In position 1 the hands can be more lateral.

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